Cardiovascular Physiology of Pregnancy

Left Ventricular Systolic Function in Pregnant Women with Inherited Thrombophilia

Objectives:The impact of the gestational changes on left ventricular contractility is not clearly defined. Our aim was to evaluate the subtle changes of left ventricular systolic function during pregnancy, assessed by new echocardiographic techniques, in a population tested for inherited thrombophilia. Material and methods:Eighty seven consecutive pregnant women, with a mean age of 32±4 years, genetically tested for inherited thrombophilia (22 with thrombophilic mutations and risk of thrombosis and 65 without significant mutations, considered as the control group) were included. All participants had four clinical and echocardiographyc visits: three during pregnancy (one in each trimester) and the forth six months after giving birth. Left ventricular (LV) systolic function was assessed from ejection fraction (EF) by 2D and 3D echocardiography, mitral annular velocities by tissue Doppler, and strain rate by 2D speckle tracking. Outcomes:There were no differences between groups for any of the echo parameters at each of the four visits. Comparing the third visit with the first one, all parameters of LV systolic function had significantly lower values at the end of pregnancy; EF decreased from 58% to 55% (2D echo), from 60% to 56% (3D TomTec), and from 58% to 55% (Auto4DLVQ), with p<0.001 for all three methods. Moreover, strain assessed by speckle traking decreased during pregnancy, with no differences between groups. In addition to this, mitral annular velocities obtained by tissue Doppler assessment decreased during the gestational period, with no differences between groups. At six months after giving birth, all values were normalized. Conclusion:During pregnancy, LV contractility has a slight decrease, with no criteria of systolic dysfunction. Thrombophilic mutations, with correct anticoagulant treatment, has no impact on LV systolic function.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

Anesthesia for Fetal Surgery and Fetal Procedures

Advances in imaging and technique have pushed the boundaries of the types of surgical interventions available to fetuses with congenital and developmental abnormalities. This review focuses on fundamental aspects of fetal anesthesia, including the physiologic changes of pregnancy, uteroplacental perfusion, and fetal physiology. We discuss the types of fetal surgeries and procedures currently being performed and discuss the specific anesthetic approaches to different categories of fetal surgeries. We also discuss ethical aspects of fetal surgery and anesthesia.

Neurosurgical Interventions for Neurotrauma in the Obstetric Population: A Systematic Review

Trauma requiring neurosurgical intervention in the obstetric population is rare. Provision of care must include consideration for both maternal and fetal well-being, and conflicts may arise. Management strategies to reduce elevated maternal intracranial pressure (ICP) and provide adequate surgical exposure, for example, may compromise uteroplacental perfusion. There is scarce literature to guide anesthetic care and few resources summarizing management of these uncommon cases. We conducted a systematic literature search for English publications of neurosurgical interventions on obstetric patients following trauma. We searched MEDLINE, EMBASE, and Google Scholar from inception to May 1, 2019. We identified 18 cases from 13 publications including 9 case reports and 4 case series. Median Glasgow coma scale on presentation was 6, good maternal outcome occurred in 39% of cases, and good fetal outcome occurred in 67% of cases. Qualitative review of the articles suggests an initially low Glasgow coma scale on admission commonly resulted in worse maternal and fetal outcomes. Delivery occurred postneurosurgical intervention in the majority of viable fetuses. Few details were available regarding anesthetic management, and ICP management strategies varied widely. Our review identified only a small number of case reports and case series. Maternal outcomes were generally poor, although the majority of fetal outcomes were good. Although there seems to be a relationship between outcomes and severity of maternal injury on presentation, it is difficult to draw conclusions or make recommendations because of limited data on perioperative anesthetic and ICP management strategies. Regardless of gestational age, maternal supremacy must be upheld. Our results are limited by the quality of the available research and potential selection bias.

CE: Gestational Hypertension, Preeclampsia, and Peripartum Cardiomyopathy: A Clinical Review

Gestational hypertension, preeclampsia, and peripartum cardiomyopathy are among the most common and often severe pregnancy-specific cardiovascular diseases (CVDs) and causes of complications in pregnancy. This clinical review provides nurses with an overview of pregnancy-specific CVDs, outlines their pathophysiology, and discusses risk factors and assessment. It describes management interventions according to timing: the antepartum, intrapartum, and postpartum phases are each addressed.

Middle Aortic Syndrome in a Child-Bearing Age Patient

We report a rare case of a 30-year-old female who had a long-standing history of middle aortic syndrome that was being managed nonsurgically. She presented with hypertension and buttock pain with plans to become pregnant. She underwent an aortoiliac bypass.

Trends of blood pressure and heart rate in normal pregnancies: a systematic review and meta-analysis

BACKGROUND

Current reference ranges for blood pressure and heart rate throughout pregnancy have a poor evidence base.

METHODS

This is a systematic review and meta-analysis. We included studies measuring blood pressure or heart rate from healthy pregnant women within defined gestational periods of 16 weeks or less. We analysed systolic blood pressure, diastolic blood pressure and heart rate by gestational age. We assessed effects of measurement year and method.

RESULTS

We included 39 studies undertaken in 1967-2017, containing 124,349 systolic measurements from 36,239 women, 124,291 diastolic measurements from 36,181 women and 10,948 heart rate measurements from 8317 women. Mean (95% CI) systolic blood pressure was lowest at 10 weeks gestation, 110.4 (108.5, 112.3) mmHg, rising to 116.0 (113.6, 118.4) mmHg at 40 weeks, mean (95% CI) change 5.6 (4.0, 7.2) mmHg. Mean (95% CI) diastolic blood pressure was lowest at 21 weeks gestation, 65.9 (64.2, 67.7) mmHg; rising to 72.8 (71.0, 74.6) mmHg at 40 weeks, mean (95% CI) change 6.9 (6.2, 7.5) mmHg. Mean (95% CI) heart rate rose from 79.3 (75.5, 83.1) beats/min at 10 weeks to 86.9 (82.2, 91.6) beats/min at 40 weeks gestation, mean (95% CI) change 7.6 (1.8, 13.4) beats/min. Studies using manual measurement reported higher diastolic blood pressures than studies using automated measurement, mean (95 CI) difference 4.9 (0.8, 8.9) mmHg. Diastolic blood pressure increased by 0.26 (95% CI 0.10-0.43) mmHg/year. Including only higher-quality studies had little effect on findings, with heterogeneity remaining high (I2 statistic > 50%).

CONCLUSIONS

Significant gestational blood pressure and heart rate changes occur that should be taken into account when assessing pregnant women. Commonly taught substantial decreases in blood pressure mid-pregnancy were not seen and heart rate increases were lower than previously thought. Manual and automated blood pressure measurement cannot be used interchangeably. Increases in diastolic blood pressure over the last half-century and differences between published studies show contemporary data are required to define current normal ranges.

STUDY REGISTRATION

PROSPERO CRD42014009673.

Stroke in Pregnancy: An Update

Pregnancy confers a substantially increased risk of stroke in women. The period of highest risk of stroke is the peripartum/postpartum phase, coinciding with the highest risk for hypertensive disorders of pregnancy and peak gestational hypercoagulability. Hemorrhagic stroke is the most common type of obstetric stroke. Hypertensive disorders of pregnancy are important contributors to obstetric stroke and predispose women to premature cardiovascular disease. The rate of stroke associated with hypertensive disorders of pregnancy has increased in the United States. Other conditions associated with obstetric stroke include posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis.

Cardiovascular and Metabolic Risk in Women in the First Year Postpartum: Allostatic Load as a Function of Race, Ethnicity, and Poverty Status

OBJECTIVE

Allostatic load (AL) represents multisystem physiological "wear-and-tear" reflecting emerging chronic disease risk. We assessed AL during the first year postpartum in a diverse community sample with known health disparities.

STUDY DESIGN

The Eunice Kennedy Shriver National Institute for Child Health and Human Development Community Child Health Network enrolled 2,448 predominantly low-income African-American, Latina, and White women immediately after delivery of liveborn infants at ≥20 weeks' gestation, following them over time with interviews, clinical measures, and biomarkers. AL at 6 and 12 months postpartum was measured by body mass index, waist:hip ratio, blood pressure, pulse, hemoglobin A1c, high-sensitive C-reactive protein, total cholesterol and high-density lipoprotein, and diurnal cortisol slope.

RESULTS

Adverse AL health-risk profiles were significantly more prevalent among African-American women compared with non-Hispanic Whites, with Latinas intermediate. Breastfeeding was protective, particularly for White women. Complications of pregnancy were associated with higher AL, and disparities persisted or worsened through the first year postpartum.

CONCLUSION

Adverse AL profiles occurred in a substantial proportion of postpartum women, and disparities did not improve from birth to 1 year. Breastfeeding was protective for the mother.

Patient blood management in obstetrics - Review

Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia, reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia. Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several medical specialties, such as cardiac, trauma and orthopedic surgery. In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited. In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its challenges in the clinical routine.

Uterine perivascular adipose tissue is a novel mediator of uterine artery blood flow and reactivity in rat pregnancy

KEY POINTS

In vivo, uterine perivascular adipose tissue (PVAT) potentiates uterine artery blood flow in pregnant rats, although not in non-pregnant rats. In isolated preparations, uterine PVAT has pro-contractile and anti-dilatory effects on uterine arteries. Pregnancy induces changes in uterine arteries that makes them responsive to uterine PVAT signalling.

ABSTRACT

An increase in uterine artery blood flow (UtBF) is a common and necessary feature of a healthy pregnancy. In the present study, we tested the hypothesis that adipose tissue surrounding uterine arteries (uterine perivascular adipose tissue; PVAT) is a novel local mediator of UtBF and uterine artery tone during pregnancy. In vivo experiments in anaesthetized Sprague-Dawley rats showed that pregnant animals (gestational day 16, term = 22--23 days) had a three-fold higher UtBF compared to non-pregnant animals. Surgical removal of uterine PVAT reduced UtBF only in pregnant rats. In a series of ex vivo bioassays, we demonstrated that uterine PVAT had pro-contractile and anti-dilatory effects on rat uterine arteries. In the presence of PVAT-conditioned media, isolated uterine arteries from both pregnant and non-pregnant rats had reduced vasodilatory responses. In non-pregnant rats, these responses were mediated at the level of uterine vascular smooth muscle, whereas, in pregnant rats, PVAT-media reduced endothelium-dependent relaxation. Pregnancy increased adipocyte size in ovarian adipose tissue but had no effect on uterine PVAT adipocyte morphology. In addition, pregnancy down-regulated the gene expression of metabolic adipokines in uterine but not in aortic PVAT. In conclusion, this is the first study to demonstrate that uterine PVAT plays a regulatory role in UtBF, at least in part, as a result of its actions on uterine artery tone. We propose that the interaction between the uterine vascular wall and its adjacent adipose tissue may provide new insights for interventions in pregnancies with adipose tissue dysfunction and abnormal UtBF.

Spontaneous coronary artery dissection: etiology and recurrence

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly appreciated cause of acute myocardial infarction (AMI) and sudden cardiac death most often affecting young to middle-aged women with few conventional cardiovascular risk factors. Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 04/30/2019). Authors review the key clinical features of SCAD and highlight what is known regarding its pathophysiology and associated factors. The relationship between SCAD and other systemic vasculopathies, notably fibromuscular dysplasia (FMD) is also discussed. Authors also mention the management of acute SCAD along with considerations for long term follow-up such as chest pain syndrome, extracoronary vasculopathy screening, and recurrent SCAD. Expert opinion: Our understanding regarding the association of SCAD and other arteriopathies such as FMD is anticipated to grow. In addition, progress is likely to be made in our efforts to predict recurrent SCAD risk and define potential preventative strategies, possibly through the incorporation of adjunctive imaging.

Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial

OBJECTIVE

To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A.

METHODS

This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5^th and 95^th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics.

RESULTS

The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35^th , 30^th or 25^th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher.

CONCLUSION

Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Heart disease and pregnancy: State of the art

The association between heart disease and pregnancy is increasingly prevalent. Although most women with heart disease tolerate the physiological changes of pregnancy, there are heart conditions that manifest for the first time during pregnancy and others that totally contraindicate a pregnancy. It is therefore important to establish multidisciplinary teams dedicated to the management of women with heart disease who intend to become, or who already are, pregnant. The aim of this article is to systematically review current knowledge on the approach to women with high-risk cardiovascular disease during pregnancy.

Advanced maternal age and the impact on maternal and offspring cardiovascular health

Delaying pregnancy, which is on the rise, may increase the risk of cardiovascular disease in both women and their children. The physiological mechanisms that lead to these effects are not fully understood but may involve inadequate adaptations of the maternal cardiovascular system to pregnancy. Indeed, there is abundant evidence in the literature that a fetus developing in a suboptimal in utero environment (such as in pregnancies complicated by fetal growth restriction, preterm birth, and/or preeclampsia) is at an increased risk of cardiovascular disease in adulthood, the developmental origins of health and disease theory. Although women of advanced age are at a significantly increased risk of pregnancy complications, there is limited information as to whether advanced maternal age constitutes an added stressor on the prenatal environment of the fetus, and whether or not this is secondary to impaired cardiovascular function during pregnancy. This review summarizes the current literature available on the impact of advanced maternal age on cardiovascular adaptations to pregnancy and the role of maternal age on long-term health risks for both the mother and offspring.

The Role of Nitric Oxide, ADMA, and Homocysteine in The Etiopathogenesis of Preeclampsia-Review

Preeclampsia is a serious, pregnancy-specific, multi-organ disease process of compound aetiology. It affects 3–6% of expecting mothers worldwide and it persists as a leading cause of maternal and foetal morbidity and mortality. In fact, hallmark features of preeclampsia (PE) result from vessel involvement and demonstrate maternal endothelium as a target tissue. Growing evidence suggests that chronic placental hypoperfusion triggers the production and release of certain agents that are responsible for endothelial activation and injury. In this review, we will present the latest findings on the role of nitric oxide, asymmetric dimethylarginine (ADMA), and homocysteine in the etiopathogenesis of preeclampsia and their possible clinical implications.

Pregnancy Complications as a Window to Future Cardiovascular Disease

Pregnancy is a time of significant hemodynamic, metabolic, and hormonal stress that can unmask underlying subclinical cardiovascular abnormalities, and pregnancy-related complications may serve as early warning signs for future risk of cardiovascular disease. The increased recognition of these sex-specific risk factors could identify women who may benefit from more intensive risk factor modification to reduce morbidity and mortality later in life. In this review, we describe several pregnancy-related complications that have been associated with the risk of cardiovascular disease, including hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm delivery, and pregnancy loss. Pregnancy-associated risk factors must be identified to fully assess a woman's future cardiovascular risk and may influence strategies for risk reduction.

Pre-eclampsia through the eyes of the obstetrician and anesthesiologist

Due to the high risk of morbidity and mortality from unrecognized and untreated pre-eclampsia, clinicians should have a high index of suspicion to evaluate, treat and monitor patients presenting with signs concerning for pre-eclampsia. Early blood pressure management and seizure prophylaxis during labor are critical for maternal safety. Intrapartum, special anesthetic considerations should be employed to ensure the safety of the parturient and fetus. Patients who have pre-eclampsia should be aware that they are at high risk for the future development of cardiovascular disease.

Hypertension in pregnancy: Pathophysiology and treatment

Hypertensive disorders of pregnancy, an umbrella term that includes preexisting and gestational hypertension, preeclampsia, and eclampsia, complicate up to 10% of pregnancies and represent a significant cause of maternal and perinatal morbidity and mortality. Despite the differences in guidelines, there appears to be consensus that severe hypertension and non-severe hypertension with evidence of end-organ damage need to be controlled; yet the ideal target ranges below 160/110 mmHg remain a source of debate. This review outlines the definition, pathophysiology, goals of therapy, and treatment agents used in hypertensive disorders of pregnancy.

Preeclampsia and future stroke risk in women: What NPs need to know

Preeclampsia is a complication of pregnancy that affects approximately 4% of pregnancies. Preeclampsia is defined as new-onset hypertension after 20 weeks gestation often accompanied by new-onset proteinuria. Women who experience preeclampsia during pregnancy are at an increased risk for hypertension and stroke later in life. Healthcare providers should screen women appropriately to minimize risk.

Pulmonary Arterial Hypertension and Pregnancy: Single Center Experience in Current Era of Targeted Therapy

Objectives

To report our experiences in pregnant patients with pulmonary arterial hypertension (PAH) who were treated with targeted therapy.

Methods

From 2011 to 2017, women who decided to maintain pregnancies in our PAH clinic were included. Clinical data, management, and outcomes of the mothers and fetuses were reviewed.

Results

Nine women with PAH and 10 deliveries were reviewed. The median maternal age was 28 (26–32) years old. The functional status of each patient was New York Heart Association functional class II or III at first visit. Sildenafil was prescribed in advance in 9 cases of delivery. Multidiscipline team approach management and intensive care were performed during the peripartum period. There was no maternal or fetal mortality. Severe cardiac events occurred in 2 patients with Eisenmenger syndrome: cardiac arrest and uncontrolled arrhythmia. Non-cardiac events occurred in 3 cases: postpartum bleeding, urinary tract infection, and pneumonia. The median gestational period at delivery was about 34 (32–38) weeks. Three cases were emergent delivery because of unexpected preterm labor. Intrauterine growth restriction developed in 4 fetuses.

Conclusions

Pregnancy could be maintained by the introduction of targeted therapy rather more safely than the previous era in the case of maintenance of pregnancy. Intensive care and a multidisciplinary team approach can possibly improve the outcomes of the pregnant women with PAH and their babies. However, pregnancy in patients with PAH is still strongly prohibited and it can be tried in expert center where there has sufficient multidisciplinary team approach in case of inevitability.

Resuscitation of the Pregnant Patient

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.

Gestational hypertensive disorders show unique patterns of circulatory deterioration with ongoing pregnancy

A combined assessment of heart, arteries, veins, and body fluid content throughout pregnancy has not yet been reported. We hypothesized that a gradual aggravation of circulatory dysfunction exists from the latent to the clinical phase of gestational hypertensive disease (GHD), and that pathways are unique for preeclampsia with early onset < 34 wk (EPE) and late onset ≥ 34 wk (LPE), and gestational hypertension (GH). Women with singleton pregnancy and no known diseases were invited for a prospective, observational study and had standardized sphygmomanometric blood pressure measurement, bioimpedance body water spectrum analysis, impedance cardiography for cardiac and arterial assessment, and combined Doppler-ECG of hepatic and renal interlobar veins and uterine arteries. Outcome was categorized as uncomplicated (UP, n = 1,700), EPE ( n = 87), LPE ( n = 218), or GH ( n = 188). A linear mixed model for repeated measurements, corrected for age, parity, and body mass index, was employed in SAS 9.4 to analyze trimestral changes within and between groups. From the first to the third trimester, body water increased in all groups, and an increasing number of abnormal parameters relative to UP occurred in all GHD. First-trimester blood pressure and peripheral resistance were higher in GHD than UP, together with increased uterine flow resistance and extracellular water in EPE, and with lower heart rate and aorta flow velocity in LPE. An overall gestational rise of body water volumes coexists with a gradual worsening of cardiovascular dysfunction in GHD, of which pathophysiological pathways are unique for EPE, LPE, and GH, respectively.

Role of pregnancy hormones and hormonal interaction on the maternal cardiovascular system: a literature review

Hormones have a vital duty in the conservation of physiological cardiovascular function during pregnancy. Alterations in oestrogen, progesterone and prolactin levels are associated with changes in the cardiovascular system to support the growing foetus and counteract pregnancy stresses. Pregnancy hormones are, however, also linked to numerous pathophysiological outcomes on the cardiovascular system. The expression and effects of the three main pregnancy hormones (oestrogen, prolactin and progesterone) vary depending on the gestation period. However, the reaction of a target cell also depends on the abundance of hormone receptors and impacts put forth by other hormones. Hormonal interaction may be synergistic, antagonistic or permissive. It is crucial to explore the cross talk of pregnancy hormones during gestation, as this may have a greater impact on the overall changes to the cardiovascular system.

Physiologic and Hemodynamic Changes During Pregnancy

Substantial physiologic changes accompany pregnancy, the most profound of which involve the cardiovascular system. These changes affect maternal hemodynamic and oxygen transport status. This article describes cardiovascular changes that occur during pregnancy including blood volume, heart rate, stroke volume, cardiac output, vascular resistance, and colloid osmotic pressure. Alterations in factors related to maternal oxygen transport including oxygen affinity, delivery, and consumption also are described. Concepts related to fetal oxygen transport and adaptive responses to hypoxemia are presented. Technical considerations regarding assessment of maternal hemodynamic and oxygen transport status during pregnancy are described and assessment findings during labor, birth, and the immediate postpartum period are interpreted. A maternal hemodynamic and oxygen transport profile is presented to illustrate these principles in clinical practice.

Blood pressure changes during pregnancy in relation to urinary paraben, triclosan and benzophenone concentrations: A repeated measures study

Previous studies have proven the endocrine-disrupting properties and health hazards of parabens, triclosan, and benzophenones, but their relationship with blood pressure during pregnancy remains unknown. Therefore, we investigated the associations of repeated measures of urinary parabens, triclosan, and benzophenones with blood pressure during pregnancy and evaluated whether the associations were modified by fetal sex. From a prospective birth cohort in Wuhan, China, we collected urine samples from 644 pregnant women in the first, second, and third trimesters between 2014 and 2015. Five parabens, triclosan, and three benzophenones were quantified in all urine samples. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in each trimester after urine sampling. Mixed linear models were used to estimate the associations between urinary chemical levels and blood pressure during pregnancy among all pregnant women and subgroups stratified by fetal sex. In the women carrying male fetuses, urinary triclosan and selected benzophenone concentrations were associated with a slight change of SBP during pregnancy. In the women carrying female fetuses, no chemical was associated with SBP, while urinary concentration of triclosan was inversely associated with DBP, though the magnitude was small. Urinary paraben levels weren't associated with blood pressure during pregnancy. Our results suggest that triclosan and selected benzophenone exposure might be associated with blood pressure during pregnancy in a potential fetal sex-different manner. Replicated research studies in pregnant women with higher triclosan and benzophenone exposure levels are needed in the future.

Parity and risk of maternal cardiovascular disease: A dose-response meta-analysis of cohort studies

BACKGROUND

Parity has been reported to play an important role in the development of cardiovascular disease; however, the results are still controversial. We aimed to conduct a meta-analysis of cohort studies to assess quantitatively the association between parity and cardiovascular disease risk.

METHODS

PubMed and Web of Science databases were searched to 1 June 2018, supplemented by manual searches of the bibliographies of retrieved articles. And multivariate-adjusted relative risks were pooled by using random-effects models. Restricted cubic spline analysis with four knots was used to explore the relationship of parity and the risk of cardiovascular disease.

RESULTS

Ten cohort studies involving 150,512 incident cases of cardiovascular disease among 3,089,929 participants were included in the meta-analysis. A significant association between parity and cardiovascular disease risk was observed while comparing parity with nulliparity, with a summarised relative risk of 1.14 (95% confidence interval (CI) 1.09-1.18; I² = 62.0%, P = 0.002). In the dose-response analysis, we observed a potential non-linear J-shaped dose-response relationship between the number of parity and cardiovascular disease risk, the summary risk estimates for an increase of one live birth was 1.04 (95% CI 1.02-1.05), with significant heterogeneity ( I² = 89.6%). In addition, the similar J-shaped associations between parturition number and cardiovascular disease, ischaemic heart disease or stroke risk were also observed.

CONCLUSIONS

Our findings suggest that ever parity is related to cardiovascular disease risk and there is an association between the number of pregnancies and the risk of cardiovascular disease. Since the number of included studies was limited, further studies are warranted to confirm our findings.

Sex differences in the vascular function and related mechanisms: role of 17β-estradiol

The incidence of cardiovascular disease (CVD) is lower in premenopausal women but increases with age and menopause compared with similarly aged men. Based on the prevalence of CVD in postmenopausal women, sex hormone-dependent mechanisms have been postulated to be the primary factors responsible for the protection from CVD in premenopausal women. Recent Women’s Health Initiative studies, Cochrane Review studies, the Early Versus Late Intervention Trial with Estradiol Study, and the Kronos Early Estrogen Prevention Study have suggested that beneficial effects of hormone replacement therapy (HRT) are seen in women of <60 yr of age and if initiated within <10 yr of menopause. In contrast, the beneficial effects of HRT are not seen in women of >60 yr of age and if commenced after 10 yr of menopause. The higher incidence of CVD and the failure of HRT in postmenopausal aged women could be partly associated with fundamental differences in the vascular structure and function between men and women and in between pre- and postmenopausal women, respectively. In this regard, previous studies from human and animal studies have identified several sex differences in vascular function and associated mechanisms. The female sex hormone 17β-estradiol regulates the majority of these mechanisms. In this review, we summarize the sex differences in vascular structure, myogenic properties, endothelium-dependent and -independent mechanisms, and the role of 17β-estradiol in the regulation of vascular function.

The management of hypertension in women planning for pregnancy

INTRODUCTION OR BACKGROUND

Poorly-controlled hypertension in the first trimester significantly increases maternal and fetal morbidity and mortality. The majority of guidelines and clinical trials focus on the management and treatments for hypertension during pregnancy and breast-feeding, while limited evidence could be applied to the management for hypertension before pregnancy. In this review, we summarized the existing guidelines and treatments of pre-pregnancy treatment of hypertension.

SOURCES OF DATA

PubMed.

AREAS OF AGREEMENT

Methyldopa and labetalol are considered the first choice, but angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) need to be withdrawn if a hypertensive woman wishes to become pregnant. In women with chronic hypertension, it is very important to make an assessment before conception to exclude secondary causes of hypertension, evaluate their hypertensive control to ensure that it is optimal, discuss the increased risks of pre-eclampsia, and provide education regarding any drug alterations before they become pregnant.

AREAS OF CONTROVERSY

There is increasing debate regarding discouraging the use of diuretics. There is also controversy regarding the use of supplementations such as calcium, antioxidants and low-dose aspirin.

GROWING POINTS

A less restricted blood-pressure goal could be set for hypertensive women planning for pregnancy. A healthy body weight before pregnancy could lower the risk of pregnancy-related hypertensive disorders. Recent guidelines also encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt before pregnancy.

TIMELY AREAS FOR DEVELOPING RESEARCH

Large, worldwide, randomized trials should be conducted to see the outcomes for hypertensive women who take antioxidants/physical activity before pregnancy.

The association of traffic-related air and noise pollution with maternal blood pressure and hypertensive disorders of pregnancy in the HOME study cohort

Traffic-related air and noise pollution may increase the risk for cardiovascular disorders, especially among susceptible populations like pregnant women. The objective of this study was to evaluate the association of exposure to traffic-related air pollution and traffic noise with blood pressure in pregnant women. We extracted systolic blood pressure (SBP) and diastolic blood pressure (DBP) at ≥20 weeks gestation, as well as hypertensive disorders of pregnancy from medical records in the HOME Study, a prospective pregnancy and birth cohort from Cincinnati, OH (n = 370). We estimated exposure to elemental carbon attributable to traffic (ECAT),1 a marker of traffic-related air pollution, at women's residences at ~20 weeks gestation using a validated land use regression model and traffic noise using a publicly available transportation noise model. We used linear mixed models and modified Poisson regression adjusted for covariates to examine associations of ECAT and traffic noise with blood pressure and hypertensive disorders of pregnancy risk, respectively. In adjusted models, we found a 1.6 (95% CI = 0.02, 3.3; p = 0.048) mm Hg increase in SBP associated with an interquartile range increase in ECAT concentration; the association was stronger after adjusting for traffic noise (1.9 mm Hg, 95% = 0.1, 3.7; p = 0.035). ECAT concentrations were not significantly associated with DBP or hypertensive disorders of pregnancy, and traffic noise was not associated with SBP, DBP, or hypertensive disorders of pregnancy. There was no evidence of a joint effect of traffic noise and ECAT on any outcome. In this cohort, higher residential traffic-related air pollution exposure at ~20 weeks gestation was associated with higher SBP in late pregnancy. It is important for future studies of traffic-related air or noise pollution to jointly consider both exposures and neighborhood characteristics given their correlation and potential cumulative impact on cardiovascular health.

Serum Calcium and Magnesium Levels in Normal Ghanaian Pregnant Women: A Comparative Cross-Sectional Study

BACKGROUND:

Pregnancy is described as a normal physiologic state associated with various biochemical changes. Magnesium and calcium are essential macronutrients required for foetal growth. Complications associated with their deficiency during normal pregnancy include; low neonatal birth weight, pre-eclampsia, eclampsia and preterm labour. Changes in serum levels of magnesium and calcium in normal pregnancy have not been extensively studied among Ghanaian women.

AIM:

To determine the variation in serum magnesium and calcium levels with gestational age in normal pregnancy in Ghanaian women.

METHODS:

A hospital-based comparative cross-sectional study was conducted among 32 normal non-pregnant women (Group A) and 100 normal pregnant women (Group B) attending the clinic at the Korle-Bu Teaching hospital. The group B pregnant women were further divided into Group B1 (n = 33), Group B2 (n = 37) and Group B3 (n = 30) based on their pregnancy gestation as first, second and third trimester respectively. Blood samples were obtained from the antecubital vein of subjects and total serum calcium, magnesium, protein and albumin were estimated. Data obtained were analysed using SPSS for windows version 20. Analysis of variance (ANOVA) was employed to determine the statistical differences between the groups. A p-value of ≤ 0.05 was considered significant.

RESULTS:

Mean serum total calcium and magnesium in first, second and third trimester normal pregnant women were 2.14 ± 0.16, 2.13 ± 0.44, 2.13 ± 0.35 mmol/L and 0.77 ± 0.11, 0.77 ± 0.16 and 0.76 ± 0.14 mmol/L respectively. Mean serum total calcium and magnesium levels in non-pregnant women were 2.20 ± 0.16 and 0.80 ± 0.10 mmol/L respectively. There was a statistically non-significant difference in serum total calcium and magnesium between non-pregnant and normal pregnant women, with p-values of 0.779 and 0.566 respectively. Mean total serum protein and albumin in first, second and third-trimester normal pregnant women were 68.42 ± 10.37, 70.46 ± 6.84, 66.70 ± 7.83 g/L and 39.92 ± 3.22, 40.75 ± 8.06, 38.26 ± 3.02 g/L respectively. Mean total serum protein and albumin in non-pregnant women were 73.13 ± 7.02 and 42.94 ± 3.03 g/L respectively. Mean total serum protein and albumin levels were lower in pregnant women as compared to non-pregnant women with the difference being significant in the third trimester (p-values of 0.012 and 0.002).

CONCLUSION:

Total serum calcium and magnesium levels in normal pregnancy were non-significantly lower compared to non-pregnant women in Ghana. There was a reduction in total serum protein, and albumin levels during pregnancy with a significant reduction noticed during the third trimester compared to the non-pregnant state.

Review of Cardiovascular Drugs in Pregnancy

Cardiovascular disease is now the leading cause of pregnancy-related deaths in the United States. Increasing maternal mortality in the United States underscores the importance of proper cardiovascular management. Significant physiological changes during pregnancy affect the heart's ability to respond to pathological processes such as hypertension and heart failure. These physiological changes further affect the pharmacokinetic and pharmacodynamic properties of cardiac medications. During pregnancy, these changes can significantly alter medication efficacy and metabolism. This article systematically reviews the literature on safety, efficacy, pharmacokinetics, and pharmacodynamics of cardiovascular drugs used for hypertension and heart failure during pregnancy and lactation. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively. Medications that block the renin angiotensin-aldosterone system have been shown to be beneficial in the general population; however, they are teratogenic and, therefore, contraindicated in pregnancy. Cardiovascular medications can also enter breast milk and, therefore, care must be taken when selecting drugs during the lactation period. A summary of the safety of drugs during pregnancy and lactation from an online resource, LactMed by the National Library of Medicine's TOXNET database, is included. High-risk pregnant patients with cardiovascular disease require a multispecialty team of doctors, including health care providers from obstetrics and gynecology, maternal fetal medicine, internal medicine, cardiovascular disease specialists, and specialized pharmacology expertise.

Validation of the iHealth Track and Omron HEM-9210T automated blood pressure devices for use in pregnancy

OBJECTIVE

Self monitoring of blood pressure in pregnancy is increasingly popular with both health care professionals and patients. We assessed the validity of the iHealth Track and Omron HEM-9210T automated blood pressure devices (with Bluetooth connectivity) for the use in telemonitoring of blood pressure in pregnancy.

METHODS

In this prospective observational study, the revised 2010 International Protocol of the European Hypertension Society (EHS) was used for the validation of the two devices against auscultatory sphygmomanometry by two independent observers who took 13 same arm measurements in 33 pregnant women, of which 10 were diagnosed with preeclampsia. The measurements were alternated between the test device and a calibrated aneroid sphygmomanometer following the protocol. Both automated devices were assessed sequentially in the same women.

RESULTS

In the group of 33 women, the iHealth Track passed the EHS 2010 validation criteria with 86/98/99 of 99 device-observer systolic measurement comparisons and 88/96/98 of 99 device-observer diastolic measurement comparisons within the 5/10/15 mmHg boundaries respectively. The Omron HEM-9210T passed the same criteria with 85/94/99 of 99 device-observer systolic measurement comparisons and 82/95/99 of 99 device-observer diastolic measurement comparisons.

CONCLUSIONS

The iHealth Track and Omron HEM-9210T automated blood pressure monitors are validated for use in pregnancy. These two devices can now be added to the short list of validated devices in pregnancy and can be used for self-measurement of blood pressure in a telemonitoring setting of pregnant patients with (a high risk of) hypertensive disease.

Incidence of myocardial infarction in pregnancy: a systematic review and meta-analysis of population-based studies

Aims

Cardiac disease is one of the leading causes of indirect maternal death, and myocardial infarction (MI) is one of its most common aetiologies. The objectives of this systematic review and meta-analysis were to characterize the incidence of pregnancy-associated MI (PAMI), as well as the maternal mortality and the case-fatality rates due to PAMI.

Methods and results

Articles were obtained by searching electronic databases, bibliographies and conference proceedings with no language or date restrictions. Two reviewers independently selected population-based cohort and case-control studies reporting on incidence, mortality and case-fatality rates for pregnancy-associated MI. Meta-analysis was performed to estimate pooled maternal incidence, mortality and case-fatality rates. Meta-regression was performed to explore heterogeneity. Based on 17 included studies, the pooled incidence of PAMI and maternal mortality from PAMI were 3.34 (2.09–4.58) and 0.20 (0.10–0.29) per 100 000 pregnancies, respectively. The case-fatality rate was 5.03% (3.78–6.27%). Country/region (meta-regression P = 0.006) and years of study (meta-regression P = 0.04) were potential explanations for the observed heterogeneity in the pooled incidence estimates of maternal MI and its associated mortality, with more recent studies and those conducted in the USA revealing the highest rates.

Conclusion

This article provides a global estimate of the incidence, mortality rate, and case fatality rate of pregnancy-associated MI. We identified higher rates of PAMI in the USA (relative to Canada and European countries) and rising rates over time. Further research regarding this population is needed, especially given rising maternal age and the increasing prevalence of cardiovascular risk factors.

Differences in visit-to-visit blood pressure variability between normotensive and hypertensive pregnant women

We evaluated the relationship between blood pressure variability (BPV) and the development of hypertension during pregnancy. A total of 4163 pregnant women with normal blood pressure (BP) before 20 weeks of gestation were included in this study. The visit-to-visit blood pressure variability (VVV) was evaluated using the standard deviation (SD) of the systolic BP taken three times during pregnancy at approximately 10, 20, and 30 weeks of gestation. The VVV gradually decreased during pregnancy in normotensive subjects (SD: 7.2 ± 4.2 mmHg, 6.8 ± 3.9 mmHg, and 6.3 ± 3.6 mmHg at 10, 20, and 30 weeks, respectively). However, the VVV of hypertensive subjects did not decrease (SD: 8.2 ± 5.7 mmHg, 7.6 ± 5.0 mmHg, and 8.3 ± 5.3 mmHg at 10, 20, and 30 weeks, respectively) and was significantly greater than the VVV of normotensive subjects (p < 0.001). The VVV was significantly higher in patients who developed hypertension, and there was no decrease in VVV during pregnancy. Pregnancy complications were significantly increased in women with higher VVV at 10 and 30 weeks. Therefore, increased VVV during pregnancy may be a predictor of poor pregnancy outcomes.

Time course of changes in maternal left ventricular function during subsequent pregnancy in women with a history of gestational hypertensive disorders

Women with a history of gestational hypertensive disorders (GHD) are at increased risk for developing perinatal cardiovascular complications (e.g., gestational hypertension, preeclampsia, etc.) in subsequent pregnancies. The underlying mechanisms remain uncertain, but impaired maternal left ventricular function may be one contributing factor for these complications. We evaluated the time course of changes in left ventricular function before, during, and after pregnancy in women with prior GHD. Sixteen women with a history of GHD (the high-risk group) and 25 women without such a history (controls) were enrolled. Resting hemodynamic and echocardiographic measurements were longitudinally performed before pregnancy, during early pregnancy (4-8 wk of gestation), during late pregnancy (32-36 wk of gestation), and postpartum (6-10 wk after delivery). Pregnancy outcomes were obtained after delivery. At prepregnancy, there was no difference in blood pressure and heart rate between the groups. Corrected isovolumic relaxation time was longer, E/ e' was larger, and Tei index was greater in the high-risk group than controls. Moreover, the rate of GHD during the study was significantly greater in the high-risk group than controls [odds ratio = 8.94 (95% confidence interval: 1.55-51.5), P = 0.007]. Multiple logistic regression analysis adjusted for age demonstrated that prepregnancy E/ e' was an independent predictor for GHD ( P = 0.017). Thus, women with a history of GHD have modestly impaired cardiac function prepregnancy compared with controls, which identifies an increased susceptibility to developing cardiovascular complications during a subsequent pregnancy.

Evaluation and Management of Maternal Congenital Heart Disease: A Review

Objective

Congenital heart defects represent the most common major congenital anomalies. The objective of this review was to define the most common forms of congenital heart disease (CHD) in pregnancy, outline preconception counseling, discuss the associated morbidity and mortality of each lesion, and review current recommendations for management of CHD in pregnancy.

Evidence Acquisition

A MEDLINE search of "congenital heart disease in pregnancy" and specific conditions in pregnancy including "ventricular septal defect," "atrial septal defect," "left outflow obstruction," "right outflow obstruction," "tetralogy of Fallot," and "transposition of the great vessels" was performed.

Results

The evidence included in the review contains 18 retrospective studies, 8 meta-analyses or systematic reviews or expert opinions, 5 case reports including surgical case reports, 2 prospective studies, and 2 clinical texts.

Conclusions

Given advances in surgical and medical management, women with a history of congenital cardiac defects are more frequently reaching childbearing age and requiring obstetric care. Many women with CHD can have successful pregnancies, although there are a few conditions that confer significant maternal risk, and pregnancy may even be contraindicated. Appropriate care for women with CHD requires a knowledge of cardiac physiology in pregnancy, the common lesions of CHD, and coordinated care from cardiology and maternal-fetal medicine specialists.

Effects of dietary nitrate supplementation, from beetroot juice, on blood pressure in hypertensive pregnant women: A randomised, double-blind, placebo-controlled feasibility trial

Chronic hypertension in pregnancy is associated with significant adverse pregnancy outcomes, increasing the risk of pre-eclampsia, fetal growth restriction and preterm birth. Dietary nitrate, abundant in green leafy vegetables and beetroot, is reduced in vivo to nitrite and subsequently nitric oxide, and has been demonstrated to lower blood pressure, improve vascular compliance and enhance blood flow in non-pregnant humans and animals. The primary aims of this study were to determine the acceptability and efficacy of dietary nitrate supplementation, in the form of beetroot juice, to lower blood pressure in hypertensive pregnant women. In this double-blind, placebo-controlled feasibility trial, 40 pregnant women received either daily nitrate supplementation (70 mL beetroot juice, n = 20) or placebo (70 mL nitrate-depleted beetroot juice, n = 20) for 8 days. Blood pressure, cardiovascular function and uteroplacental blood flow was assessed at baseline and following acute (3 h) and prolonged (8 days) supplementation. Plasma and salivary samples were collected for analysis of nitrate and nitrite concentrations and acceptability of this dietary intervention was assessed based on questionnaire feedback. Dietary nitrate significantly increased plasma and salivary nitrate/nitrite concentrations compared with placebo juice (p < 0.001), with marked variation between women. Compared with placebo, there was no overall reduction in blood pressure in the nitrate-treated group; however there was a highly significant correlation between changes in plasma nitrite concentrations and changes in diastolic blood pressure in the nitrate-treated arm only (r = -0.6481; p = 0.0042). Beetroot juice supplementation was an acceptable dietary intervention to 97% of women. This trial confirms acceptability and potential efficacy of dietary nitrate supplementation in pregnant women. Conversion of nitrate to nitrite critically involves oral bacterial nitrate reductase activities. We speculate that differences in efficacy of nitrate supplementation relate to differences in the oral microbiome, which will be investigated in future studies.

Anemia in Pregnancy: A Pragmatic Approach

Importance

Anemia is common in pregnancy, ranging from 5.4% in developed countries to more than 80% in developing countries. Anemia in pregnancy has been associated with prematurity, low birth weight, and adverse pregnancy outcomes.

Objective

This review uses clinical vignettes to illustrate the clinical presentations, approach to diagnosis, maternal and fetal implications, and treatment for the common etiologies of anemia in pregnancy.

Evidence Acquisition

Literature review.

Results

Normal physiological changes in pregnancy result in alterations of hematological parameters particularly in a reduction of hemoglobin (Hb) concentration. Consequently, the Hb used to define anemia in pregnancy is lower than in nonpregnant patients. As there is an increased requirement of iron in pregnancy, it is not unexpected that iron deficiency remains the most common cause of anemia and warrants a preemptive approach to prevent a further reduction in Hb. The syndromes associated with microangiopathic hemolytic anemia may pose a diagnostic challenge, as there are several potential etiologies that may be difficult to differentiate, and microangiopathic hemolytic anemia can be associated with significant maternal and fetal morbidity andmortality. Anemia secondary to sickle cell disease and autoimmune hemolytic anemiamerit special attention because there are risks secondary to red blood cell transfusion and risks to withholding transfusion.

Conclusions

Anemia in pregnancy is potentially associated with maternal and fetal adverse outcomes. Providing evidence-based care is essential to achieving the best pregnancy outcomes.

Myocardial tissue characterization and strain analysis in healthy pregnant women using cardiovascular magnetic resonance native T1 mapping and feature tracking technique

BACKGROUND

Peripartum cardiomyopathy is a life-threatening condition that occurs during the peripartum period in previously healthy women. Cardiovascular magnetic resonance (CMR) T1 mapping permits sensitive detection of tissue edema and fibrosis, and it may be useful in identifying altered myocardial tissue characteristics in peripartum cardiomyopathy. However, left ventricular (LV) volumes and mass increase considerably even in normal pregnancy, and it is not known whether altered tissue characteristics can be found in normal pregnancy. The aim of this study was to investigate whether the LV remodeling observed in normal pregnancy is associated with altered tissue characteristics determined by CMR.

METHODS

Twelve normal pregnant women and 15 non pregnant women underwent cine CMR and myocardial T1 measurement at 1.5 T. Pregnant women were scanned three times, in the 2nd and 3rd trimesters of pregnancy and at 1 month postpartum. LV volumes, LV mass (LVM), and global longitudinal strain (GLS) were analyzed by cine CMR. Native myocardial T1 was determined using modified Look-Locker inversion recovery (MOLLI) images.

RESULTS

LV end-diastolic volume (EDV) was significantly greater in the 3rd trimester (126 ± 22 mL) than in non-pregnant women (108 ± 14 mL, p < 0.05). LVM was significantly greater in the 3rd trimester (88.7 ± 11.8 g) than at 1 month postpartum (70.0 ± 9.8 g, p < 0.05) and in non-pregnant women (66.3 ± 13.9 g, p < 0.05). Myocardial native T1 among the 2nd and 3rd trimesters, 1 month postpartum, and non-pregnant women were similar (1133 ± 55 ms, 1138 ± 86 ms, 1105 ± 45 ms, and 1129 ± 52 ms, respectively, p = 0.59) as were GLS (- 19.5 ± 1.8, - 19.7% ± 2.2, - 19.0% ± 2.0%, and - 19.3% ± 1.9%, respectively, p = 0.66).

CONCLUSIONS

LV remodeling during normal pregnancy is associated with myocardial hypertrophy, but not with edema or diffuse fibrosis of the myocardium or LV contractile dysfunction. These results observed in normal pregnancy will serve as an important basis for identifying myocardial abnormalities in patients with peripartum cardiomyopathy and other pregnancy-related myocardial diseases.

Regulators of G protein signaling in cardiovascular function during pregnancy

G protein-coupled receptor signaling mechanisms are implicated in many aspects of cardiovascular control, and dysfunction of such signaling mechanisms is commonly associated with disease states. Investigators have identified a large number of regulator of G protein signaling (RGS) proteins that variously contribute to the modulation of intracellular second-messenger signaling kinetics. These many RGS proteins each interact with a specific set of second-messenger cascades and receptor types and exhibit tissue-specific expression patterns. Increasing evidence supports the contribution of RGS proteins, or their loss, in the pathogenesis of cardiovascular dysfunctions. This review summarizes the current understanding of the functional contributions of RGS proteins, particularly within the B/R4 family, in cardiovascular disorders of pregnancy including gestational hypertension, uterine artery dysfunction, and preeclampsia.